Obstetrics Flashcards
1
Q
ECTOPIC PREGNANCY
What is an ectopic pregnancy?
What is the most common site?
What is the most common site for rupture?
A
- Implantation of a fertilised ovum outside of the uterine cavity
- Ampulla of fallopian tube
- Isthmus
2
Q
ECTOPIC PREGNANCY
What are some risk factors for ectopics?
A
- Previous ectopic (10% recurrence rate)
- Tubal damage (PID, surgery), endometriosis, IUCD, IVF, POP
3
Q
ECTOPIC PREGNANCY
What is the clinical presentation of ectopic pregnancies?
A
- Amenorrhoea for 6-8w
- PV bleeding (small amount, brown)
- Lower abdo (iliac fossa) pain (?referred shoulder tip pain if haemoperitoneum)
- Exam = abdo tenderness, cervical motion tenderness
4
Q
ECTOPIC PREGNANCY
What are some crucial investigations for ectopics?
A
- EPAU = urinary beta-hCG and transvaginal USS (positive with empty uterus)
5
Q
ECTOPIC PREGNANCY
What are the 3 management options for ectopics and their criteria?
A
- Expectant = size <35mm, unruptured, no Sx, no foetal heartbeat, hCG <1000
- Medical = size <35mm, unruptured, no major pain, no foetal heartbeat, hCG <5000
- Surgical = size ≥35mm, ruptured, pain, visible foetal heartbeat, hCG >5000
6
Q
ECTOPIC PREGNANCY
What is expectant management of ectopics?
A
- Effectively do nothing
- Requires serial serum hCG to ensure dropping (must return for follow up)
7
Q
ECTOPIC PREGNANCY
What is medical management of ectopics?
A
- Single dose IM 50mg/m^2 methotrexate
- Requires serial serum hCG to ensure dropping (must return for follow up)
8
Q
ECTOPIC PREGNANCY
What is the surgical management of ectopics?
What else may be required?
A
- Lap salpingectomy = contralateral tube + ovary healthy to reduce recurrence
- Lap salpingotomy = contralateral tube defected or absent
- Anti-D for rhesus -ve
9
Q
MISCARRIAGE
What is a miscarriage?
What is the epidemiology?
A
- Spontaneous termination of a pregnancy before 24w gestation
- 15–20% of pregnancies, no increased risk after 1 but there is after 2
10
Q
MISCARRIAGE
What are some causes of miscarriage?
A
- 1st trimester = chromosomal abnormality (risk with increased age)
- 2nd trimester = incompetent cervix e.g., previous cervical surgery, BV in 2nd trimester
11
Q
MISCARRIAGE
What are the 5 types of miscarriage?
A
- Threatened
- Inevitable
- Incomplete
- Complete
- Missed
12
Q
MISCARRIAGE
What is a threatened miscarriage?
A
- Foetus alive but miscarriage may occur (majority don’t)
- Painless vaginal bleeding with closed cervical os
- TVS = viable intrauterine pregnancy
13
Q
MISCARRIAGE
What is an inevitable miscarriage?
A
- Miscarriage will occur
- Heavy PV bleed with clots + crampy abdo pain with open cervical os
- TVS = intrauterine pregnancy
14
Q
MISCARRIAGE
What is an incomplete miscarriage?
A
- Not all POC been passed
- PV bleed, abdo pain + open cervical os with POC in canal
- Medical or surgical Mx as infection risk
15
Q
MISCARRIAGE
What is a complete miscarriage?
A
- Full miscarriage occurred with all foetal tissue passing
- May have been alerted by pain + bleeding, cervical os closed
- TVS = empty uterus
16
Q
MISCARRIAGE
What is a missed miscarriage?
A
- Foetal tissue in utero but foetus no longer alive
- Asymptomatic
- TVS = non-viable intrauterine pregnancy (smaller than expected) e.g. 12w scan shows 9w foetus with no heartbeat
17
Q
MISCARRIAGE
What is a blighted ovum?
A
- In missed miscarriage, a gestational sac >25mm but no embryonic/foetal part
18
Q
MISCARRIAGE
What is a pregnancy of unknown location?
What is the management?
A
- No sign of intrauterine/ectopic pregnancy but positive beta-hCG
- Beta-hCG >1500 = ectopic
- If no Dx after 3 samples = expectant or methotrexate Mx
19
Q
MISCARRIAGE
What are the investigations for miscarriage?
A
- EPAU = speculum, serum beta-hCG (serial should double every 48h) and transvaginal USS
20
Q
MISCARRIAGE
What is the first line management of miscarriage?
When is it not suitable?
A
- Expectant (wait 7–14d)
- Increased haemorrhage risk, previous traumatic pregnancy experience or evidence of infection
21
Q
MISCARRIAGE
What is the medical management of a miscarriage?
What is the follow up?
A
- PV misoprostol (prostaglandin analogue) with analgesia and anti-emetics
- Contact HCP if no bleeding in 24h
22
Q
MISCARRIAGE
What are the options for surgical management?
A
- Vacuum aspiration (suction curettage) under local as OP
- Surgical management under general
23
Q
MISCARRIAGE
What else may be given in the management of miscarriage?
A
- Anti-D to rhesus -ve women if >12w, heavily bleeding or surgical Mx
24
Q
MISCARRIAGE
What is a recurrent miscarriage?
A
- ≥3 consecutive miscarriages in the first trimester with the same biological father
25
MISCARRIAGE
| What are some causes of recurrent miscarriage?
- Antiphospholipid syndrome
- Hereditary thrombophilias (Factor V leiden deficiency, factor II prothrombin gene mutation, protein C/S deficiency)
- Uterine abnormalities (uterine septate)
- Endo = DM, PCOS, thyroid disease
26
MISCARRIAGE
| What are the investigations for recurrent miscarriage?
- Lupus anticoagulant + anti-cardiolipin antibodies
- Thrombophilia screen
- Pelvic USS for structural issues
- Cytogenic analysis of POC after 3rd miscarriage
27
TERMINATING PREGNANCY
| What is the legal framework for terminating pregnancies?
- 1967 Abortion Act
- 2 medical practitioners to sign legal document
- Only registered medical practitioner can perform in licensed premise
28
TERMINATING PREGNANCY
| What is the management of terminating pregnancy based on the gestation?
- <9w = mifepristone (anti-progesterone) followed 48h by misoprostol
- <13w = surgical dilation and suction of uterine contents
- ≥15w = surgical dilation and evacuation of uterine contents or late medical abortion (mini-labour)
29
TERMINATING PREGNANCY
Where might medical termination occur?
What additional management is required after 14w?
What are some complications of termination of pregnancy?
- Outpatient remotely with Marie Stopes UK
- Cervical priming witih misoprostol or osmotic dilators
- Infection, bleeding, pain + failure
30
TERMINATING PREGNANCY
| What is the post-termination management?
- Anti-D for Rh-ve women for any TOP
- Urinary pregnancy test 3w after to confirm complete
- Discuss contraception
- Offer counselling
31
HYPEREMESIS GRAVIDARUM
What is hyperemesis gravidarum thought to be related to?
What are some associations?
- Raised beta-hCG levels
| - Multiple pregnancies, molar pregnancies, hyperthyroidism, DECREASED in smokers
32
HYPEREMESIS GRAVIDARUM
What is the clinical presentation of hyperemesis gravidarum?
Complications?
- Severe + excessive N+V > Mallory Weiss tear
| - Associated with dehydration, ketosis + weight loss
33
HYPEREMESIS GRAVIDARUM
What is the diagnostic triad for hyperemesis gravidarum?
How is severity assessed?
What other investigations would you do?
Triad –
– >5% weight loss compared to before pregnancy
– Dehydration
– Electrolyte imbalance
- Pregnancy-Unique Quantification of Emesis (PUQE)
- Urine dipstick (ketones), MC&S (UTI), U&E
- TV USS ?molar pregnancy
34
HYPEREMESIS GRAVIDARUM
| What would warrant admission in hyperemesis gravidarum?
- Unable to tolerate PO antiemetics or fluids
- >5% weight loss compared to before pregnancy despite anti-emetics
- Ketones present in dipstick (++ significant)
35
HYPEREMESIS GRAVIDARUM
| What is the anti-emetic management for hyperemesis gravidarum?
- First line = antihistamines e.g., cyclizine, promethazine
- Second line = ondansetron, metoclopramide (<5d as EPSEs)
- Can trial ginger and P6 wrist acupressure
36
HYPEREMESIS GRAVIDARUM
| What is the general inpatient management of hyperemesis gravidarum?
- VTE prophylaxis = TED stockings + LMWH
- Monitor U&Es and give IV fluids (+KCl as vomiting)
- Vitamin supplements (incl. thiamine) to prevent Wernicke's encephalopathy
37
GESTATIONAL TROPHOBLASTIC DISORDERS
| What are the three types of gestational trophoblastic disorders and explain what they are?
- Complete (hydatidiform) mole = diploid trophoblast where empty egg fertilised by single sperm which duplicates its DNA so all paternal DNA
- Partial mole = triploid (XXX/XXY) trophoblast (2 sperm, 1 egg)
- Invasive = complete mole invades myometrium (metaplastic potential > choriocarcinoma which metastasises to the lungs)
38
HYDATIDIFORM MOLE
| What are some risk factors for hydatidiform mole?
- Extremes of reproductive age
- Previous molar pregnancy
- Multiple pregnancies
- Asian women
- OCP
39
HYDATIDIFORM MOLE
| What is the clinical presentation of hydatidiform mole?
- PV bleed in first trimester
- Uterus larger than expected for gestation
- Clinical hyperemesis gravidarum and thyrotoxicosis (hCG can mimic TSH)
40
HYDATIDIFORM MOLE
| What are some investigations for hydatidiform mole?
- Serum beta-hCG abnormally high
- TV USS = 'snowstorm' appearance with mixed echogenicity
- Dx confirmed with histology of mole after evacuation
41
HYDATIDIFORM MOLE
| What is the management for hydatidiform mole?
- Urgent referral to specialist centre for suction curettage to remove
- Surveillance = serum + urine hCG until normal
42
ANTENATAL CARE
What is meant by gravidity?
What is meant by parity?
What is the management of reduced foetal movements?
- Total number of PREGNANCIES
- Total number of BIRTHS ≥24w, regardless of foetal outcome
- Handheld doppler for heartbeat – USS if not heard, CTG if present
43
ANTENATAL APPTS
When is the first visit?
What is done?
Booking 8–12w (ideally <10w) –
- General info = diet, alcohol, smoking, folic acid + vitamin D advice, antenatal classes, family origin questionnaire
- FBC, blood group, rhesus status, haemoglobinopathies
- HIV, hep B + syphilis screening offered
- Urine MC&S for asymptomatic bacteriuria
44
ANTENATAL CARE
What is the recommended amount of folic acid?
What is the recommended amount of vitamin D?
- ALL 400mcg
- 5mg if – AEDs, coeliac, DM, >30kg/m^2, NTD risk
- 10 ug
45
ANTENATAL APPTS
When is the dating scan done?
When is the anomaly scan?
- Dating = 11–13+6w to confirm viability and assess for multiple pregnancy
- Anomaly = 18–20+6
46
ANTENATAL APPTS
After the anomaly scan, routine care is given.
What is routine care and when is it given?
- BP, urine dipstick and SFH ±2cm gestational age
| - 25w (primis), 28w, 31w (primis), 34w, 36w, 38w, 40w (primis), 41w
47
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ANTENATAL APPTS
When is the second anaemia screen?
When do you screen for gestational diabetes?
When do you give anti-D prophylaxis?
When do you check presentation?
```
- 28w
- 28w
- 28w and 34w
- 36w = offer external cephalic version if appropriate
48
ANTENATAL SCREENING
| What are the 3 main syndromes screened for in pregnancy?
- Patau's (trisomy 13)
- Edward's (trisomy 18)
- Down's (trisomy 21)
49
ANTENATAL SCREENING
| What screening is offered in early pregnancy and when?
Combined test (11–13+6w) –
- Nuchal translucency (thickness of back of foetus' neck on USS)
- Beta-hCG
- Pregnancy associated plasma protein-A (PAPP-A)
50
ANTENATAL SCREENING
What results indicate higher risk for...
i) nuchal translucency?
ii) beta-hCG?
iii) PAPP-A?
i) >6mm
ii) Higher result
iii) Lower result (even lower for trisomy 13 + 18)
51
ANTENATAL SCREENING
| What screening is offered if the mother is too late for the combined test and when?
Triple or quadruple test 15–20w but only tests for Down's syndrome –
- Beta-hCG (high)
- Alpha-fetoprotein (low)
- Oestriol (low)
- Inhibin (quadruple, high)
52
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ANTENATAL SCREENING
What risk score would warrant further invasive tests?
What are those tests?
What are the risks of those tests?
What other test is available privately?
```
- >1:150 = screen +ve
- Amniocentesis or chorionic villus sampling (CVS) if <15w
- Miscarriage, infection + failed samples
- Non-invasive prenatal testing = analyses foetal DNA in maternal blood
53
PLACENTA PRAEVIA
What is placenta praevia?
How is it graded?
- Placenta is inserted wholly, or in part, into the lower segment of the uterus
- I = reaches lower segment but not internal os
- II = reaches internal os but doesn't cover
- III = covers internal os before dilation but not after
- IV = completely covers internal os
54
PLACENTA PRAEVIA
| What are some risk factors for placenta praevia?
- Multiparity
- Multiple pregnancy
- PMHx praevia
- Lower segment scar from c-section
55
PLACENTA PRAEVIA
| What is the clinical presentation of placenta praevia?
- PAINLESS PV bleeding, BRIGHT RED blood, shock IN proportion to visible loss
- Foetus may have abnormal lie + presentation (transverse + breech)
56
PLACENTA PRAEVIA
| What are the investigations for placenta praevia?
- TV USS = diagnosed at 20w anomaly scan
| - Rescan at 34w then 2 weekly
57
PLACENTA PRAEVIA
| What is the management of asymptomatic placenta praevia?
- Grade I = ?vaginal delivery
| - Grade III/IV = elective c-section 37–38w but if labour starts before > crash c-section
58
PLACENTA PRAEVIA
| What is the management of placenta praevia with bleeding?
- ABCDE (2x large bore cannulae, X-match blood, IV fluids, senior) + admit
- Emergency c-section if unable to stabilise or if in labour or reached term
- Anti-D if rhesus negative
- Maternal corticosteroids if <34w gestation
59
PLACENTAL ABRUPTION
What is placental abruption?
What are some risk factors?
- Separation of a normally sited placenta from the uterine wall leading to bleeding
- Cocaine use, pre-eclampsia, maternal smoking, trauma
60
PLACENTAL ABRUPTION
| What is the clinical presentation of placental abruption?
- Sudden onset severe abdo PAIN which is continuous
- PV bleeding DARK red, shock OUT of proportion to visible loss (blood can be concealed behind placenta)
- Maternal shock, abnormal CTG
- Exam = tender "woody" uterus
61
PLACENTAL ABRUPTION
| What are the maternal and foetal complications of placental abruption?
- Shock, DIC, renal failure, PPH
| - IUGR, hypoxia + death
62
PLACENTAL ABRUPTION
What is the general management of placental abruption?
How do you manage if the foetus is alive and <36w?
- ABCDE (2x large bore cannulas, X-match blood, IV fluids, senior) + admit
- Anti-D if mother Rh-ve
- Foetal distress = immediate c-section
- No foetal distress = admit + observe closely, corticosteroids, no tocolysis
63
PLACENTAL ABRUPTION
| What is the management if the foetus is alive and >36w?
- Foetal distress = immediate c-section
| - No foetal distress = deliver vaginally
64
ADHERED PLACENTA
What is a morbidly adhered placenta?
What are some risk factors?
- The chorionic villi attach to the myometrium rather than being restricted within the decidua basalis, may cause bleeding
- Previous c-section, placenta praevia
65
ADHERED PLACENTA
| What are the different types of morbidly adhered placenta?
- Accreta = placenta invades into superficial myometrium
- Increta = placenta invades deeper through the myometrium
- Percreta = placenta invades through myometrium
66
ADHERED PLACENTA
| What are some complications of a morbidly adhered placenta?
- Delivery risks = PPH, caesarean hysterectomy, ITU admission, infection
67
ADHERED PLACENTA
| What are the investigations and management of a morbidly adhered placenta?
- USS + MRI useful
- Safest = elective c-section at 35–37w + abdominal hysterectomy
- Can trial uterus preserving surgery or expectant but risks
68
VASA PRAEVIA
What is vasa praevia?
What are some risk factors?
- Foetal vessels run near/across internal os > foetal haemorrhage
- Placenta praevia, IVF, multiple pregnancy
69
VASA PRAEVIA
| What is the clinical presentation of vasa praevia?
- PV bleed straight after rupture of foetal membranes > rapid foetal distress
- CTG abnormalities (bradycardia) but no major maternal risk
70
VASA PRAEVIA
| What is the management of vasa praevia?
- Elective c-section 35–36w or if membranes rupture > emergency c-section
71
PRE-ECLAMPSIA
| What is pre-eclampsia?
- Pregnancy induced HTN (≥140/90) after 20w pregnancy + proteinuria (>0.3g on 24h collection or +) or evidence of other organ involvement
72
PRE-ECLAMPSIA
| What is thought to be the cause of pre-eclampsia?
- Abnormal development of placenta as spiral arteries do not remodel and dilate leading to placental ischaemia + endothelial cell damage
73
PRE-ECLAMPSIA
| What are some high risk and moderate risk factors for pre-eclampsia?
- High = previous pre-eclampsia, CKD, T1/2DM, autoimmune (SLE)
- Moderate = first pregnancy, FHx, multiple pregnancy
74
PRE-ECLAMPSIA
| What is the clinical presentation of pre-eclampsia?
- Renal hypoperfusion = HTN, proteinuria + oliguria
- Retinal hypoperfusion = blurred vision, scotomas
- Liver = RUQ/epigastric pain
75
PRE-ECLAMPSIA
| What are some signs of pre-eclampsia?
- Oedema (peripheral, pulmonary and cerebral)
- Ankle clonus = brisk reflexes NORMAL in pregnancy but not clonus
- Papilloedema
76
PRE-ECLAMPSIA
What are the two main complications in pre-eclampsia?
What are some others?
- Eclampsia + HELLP syndrome
- Haemorrhage = DIC, stroke
- Foetus = IUGR, prematurity
77
PRE-ECLAMPSIA
What is eclampsia?
What is the immediate seizure management?
- Generalised tonic-clonic seizures in a patient with a Dx of pre-eclampsia
- IV magnesium sulfate to prevent + treat seizures and continue for 24h after last seizure or delivery
78
PRE-ECLAMPSIA
| What is the definitive management of eclampsia?
- Deliver the foetus
79
PRE-ECLAMPSIA
What needs to be monitored when giving magnesium sulfate?
How is this managed?
- Magnesium levels for toxicity
- Reduced reflexes, confusion + respiratory depression
- Calcium gluconate first line
80
PRE-ECLAMPSIA
What is HELLP syndrome?
How might is present?
What is the management?
- Haemolysis (raised LDH), Elevated Liver enzymes + Low Platelets
- RUQ pain, N+V
- Deliver baby
81
PRE-ECLAMPSIA
What should be given to women who are at risk of pre-eclampsia?
What decides if they get it?
- 75mg aspirin PO OD at 12w until birth
| - ≥1 high risk factor, ≥2 moderate risk factors
82
PRE-ECLAMPSIA
| What is the general management of pre-eclampsia?
- Admit if BP ≥160/110mmHg
- PO labetalol = first line (nifedipine if asthma)
- Can trial hydralazine but ACEi CONTRAINDICATED
- IV magnesium sulfate to prevent seizures during labour and 24h after
- Definitive management = deliver baby
83
PRE-ECLAMPSIA
| What are the 3 other types of HTN in pregnancy conditions?
- Chronic HTN = HTN prior to pregnancy or <20w
- Gestational/pregnancy induced HTN = new HTN >20w but no proteinuria + resolves after birth
- Pre-eclampsia superimposed on chronic HTN
84
PRE-ECLAMPSIA
| What is pre-eclampsia superimposed on chronic HTN?
- HTN + no proteinuria <20w with new onset proteinuria after 20w
- HTN + proteinuria <20w but new sudden rise in proteinuria or BP
85
IUGR
| What is intrauterine growth restriction (IUGR)?
- Baby has not maintained its growth potential (slows or ceases)
86
IUGR
| What are the two types of IUGR?
- Symmetrical = entire body is proportionately small, tends to be seen with chromosomal abnormalities
- Asymmetrical = undernourished foetus that is compensating by directing energy to maintain growth of vital organs like brain + heart
87
IUGR
What is small for gestational age (SGA)?
What can cause it?
- Estimated foetal weight (EFW) or abdominal circumference (AC) below 10th centile for their gestational age
- Constitutionally small (FHx, no pathology) or due to IUGR
88
IUGR
| What is low birth weight?
- Baby born with a weight <2.5kg (regardless of gestational age)
89
IUGR
| What are the main causes of IUGR?
- Placental insufficiency (#1) = pre-eclampsia, placenta accreta + abruption, malnutrition
- Non-placental mediated (foetal) = genetic abnormalities (trisomy 13/18/21, Turner's), congenital TORCH infections
90
IUGR
| What are some risk factors for IUGR?
- HTN
- T2DM
- Smoking
- Multiple pregnancy
91
IUGR
| What are some complications of IUGR?
- Prematurity
- Hypoglycaemia
- Necrotising enterocolitis
- Hypothermia
- Neonatal jaundice
92
IUGR
| If you were concerned about IUGR, what management would they get?
- Refer for serial growth scans (every 2w to assess EFW + AC) + umbilical artery doppler (check baby getting enough blood)
- Amniotic fluid volume may be reduced
- MCA doppler after 32w
93
IUGR
| What is the management of IUGR?
- Delivery (corticosteroids if <34w) if static growth, absent end-diastolic flow on doppler or abnormal CTG
94
MACROSOMIA
What is large for gestational age?
What is macrosomia?
- Estimated foetal weight above the 90th centile for their gestational age
- Baby with a weight >4kg
95
MACROSOMIA
| What are the causes of macrosomia?
- Constitutionally large
- Maternal diabetes
- Obesity
- Previous macrosomia
- Overdue
96
MACROSOMIA
| What are some complications of macrosomia?
- Maternal = failure to progress, perineal tears, PPH
| - Foetal = shoulder dystocia, neonatal hypoglycaemia, obesity
97
MACROSOMIA
| What is the management of macrosomia?
- OGTT to screen for diabetes
- Regular growth scans to assess progress
- Check amniotic fluid index to exclude polyhydramnios
98
MULTIPLE PREGNANCY
What is the difference between monozygotic and dizygotic twins?
What are some risk factors for twins?
- Mono = identical, di = non-identical (1/2 zygotes)
| - Previous twins, FHx, increasing maternal age, IVF
99
MULTIPLE PREGNANCY
| What are some complications of multiple pregnancy?
- Antenatal/labour = APH, polyhydramnios, PPH
| - Foetal = prematurity, twin-twin transfusion syndrome, IUGR
100
MULTIPLE PREGNANCY
| What is twin-twin transfusion syndrome?
- Associated with monoamniotic monozygotic twins
- Recipient gets majority of blood so is larger with polyhydramnios and donor starved of blood > anaemic
- Severe = laser ablation of connecting vessels
101
MULTIPLE PREGNANCY
| What is the management of multiple pregnancies?
- Steroids if <34w
| - Additional scans, iron + folate
102
OLIGOHYDRAMNIOS
What is oligohydramnios?
What are some complications?
- Low levels of amniotic fluid, usually amniotic fluid index <5th centile
- Pulmonary hypoplasia, muscle contractures, prematurity
103
OLIGOHYDRAMNIOS
| What are some causes of oligohydramnios?
- Premature rupture of membranes
- Foetal renal problems = agenesis (Potter's syndrome)
- IUGR
- Post-term gestation
104
OLIGOHYDRAMNIOS
| What is the management of oligohydramnios?
- USS to calculate AFI or maximum pool depth + monitor for IUGR
105
POLYHYDRAMNIOS
| What is amniotic fluid (liquor)?
- Fluid between baby + amnion (sac) acts as a cushion around foetus to protect it from trauma
- Foetus can swallow amniotic fluid which helps create urine + meconium
106
POLYHYDRAMNIOS
| What is polyhydramnios?
- Abnormally large levels of amniotic fluid, usually AFI >95th centile
107
POLYHYDRAMNIOS
| What are the causes of polyhydramnios?
- Increased foetal urination = maternal DM, TTTS, foetal anaemia
- Insufficient removal = oesophageal or duodenal atresia, diaphragmatic hernia
108
POLYHYDRAMNIOS
| What are some complications of polyhydramnios?
- Maternal = respiratory compromise, UTIs, c-section need
| - Foetal = prematurity, malpresentation, umbilical cord prolapse
109
POLYHYDRAMNIOS
| What is the management of polyhydramnios?
- Exclude maternal diabetes with OGTT
- USS monitoring = AFI or maximum pool depth
- Amnioreduction in severe cases
110
RHESUS DISEASE
| What is the pathophysiology of rhesus disease?
- Rhesus -ve woman + rhesus +ve foetal blood = antibodies against Rh D (sensitisation) but no issues in that pregnancy as IgM cannot cross placenta
- Subsequent = IgG crosses placenta causing haemolytic disease of newborn
111
RHESUS DISEASE
| What investigations would you do if you suspected rhesus disease?
- Kleihauer test to check how much foetal blood > mother's blood after sensitising event (add acid to maternal blood as foetal cells resistant)
- All babies born to Rh-ve women have cord blood at delivery for FBC, blood group + Direct Coombs (antiglobulin) test for Ab on baby's RBCs
112
RHESUS DISEASE
| What is the management of rhesus disease?
- Prophylaxis crucial as sensitisation is irreversible
| - IM anti-D immunoglobulin attaches to RhD antigens to avoid recognition
113
RHESUS DISEASE
| When is anti-D given?
- 28w + 34w routinely
| - Sensitising events = APH, amniocentesis/CVS, ECV
114
CHORIOAMNIONITIS
What is chorioamnionitis?
What is a major factor in the condition?
- Ascending bacterial infection of amniotic fluid, membranes or placenta
- PPROM
115
CHORIOAMNIONITIS
| What is the clinical presentation of chorioamnionitis?
- Fever, abdominal pain + offensive vaginal discharge
| - Evidence of PPROM
116
CHORIOAMNIONITIS
| What is the management of chorioamnionitis?
- Deliver foetus (corticosteroids if <34w)
| - Broad spectrum IV Abx as part of sepsis six
117
GESTATIONAL DIABETES
| What is Gestational Diabetes Mellitus (GDM)?
- Increased insulin resistance as placental production of anti-insulin hormones like human placental lactogen
118
GESTATIONAL DIABETES
| What are some risk factors for GDM?
- BMI >30kg/m^2
- PMH of GDM
- FHx of DM (first-degree)
- Asian ethnicity
- Previous macrosomic baby
119
GESTATIONAL DIABETES
What is the diagnostic investigation for GDM?
Who is given this?
- OGTT
- Anyone with previous GDM at booking + 24–28w
- Anyone with risk factors at 24-28w
120
GESTATIONAL DIABETES
| What OGTT results are diagnostic for GDM?
5-6-7-8 rule:
- Baseline/fasting ≥5.6mmol/L
- At 2h ≥7.8mmol/L
121
GESTATIONAL DIABETES
| What are the complications of GDM?
- Foetal = macrosomia, polyhydramnios, prematurity, obesity
| - Maternal = DKA, hypoglycaemia, nephropathy
122
GESTATIONAL DIABETES
What is the management of GDM?
What is an alternative treatment?
- Fasting glucose <7 = lifestyle changes (exercise, low glycaemic index)
- Fasting glucose ≥7 or ≥6 and complications = start short acting insulin ± metformin
- Glibenclamide if cannot tolerate metformin or decline insulin
123
GESTATIONAL DIABETES
What is the management of GDM if the fasting glucose is <7 and they have trialled lifestyle changes but still below target?
- 1–2w = add metformin
| - If still not met with metformin = add insulin (short acting)
124
GESTATIONAL DIABETES
| What is the management of pre-existing diabetes in pregnancy?
- Stop PO hypoglycaemics apart from metformin + start insulin (short-acting)
- Folic acid 5mg/day from pre-conception to 12w
125
VTE IN PREGNANCY
| What are some risk factors of VTE in pregnancy?
- PMHx VTE, thrombophilia = major
| - BMI >30, smoking, varicose veins, immobility, age >35
126
VTE IN PREGNANCY
| How do you manage VTE risk antenatally?
- VTE risk assessment at booking + during admissions
- ≥4 risk factors = immediate LMWH + continue 6w postnatally
- 3 risk factors = LMWH from 28w + continue 6w postnatally
- TED stockings
127
VTE IN PREGNANCY
What should you not prescribe in VTE?
How would you investigate VTE?
- Warfarin or DOACs
- DVT + PE = just USS doppler
- CXR, V/Q scan is preferred in pregnancy
128
OBSTETRIC CHOLESTASIS
| What is obstetric cholestasis?
- Intrahepatic cholestasis = reduced outflow of bile acids from liver
129
OBSTETRIC CHOLESTASIS
| What are some clinical features of obstetric cholestasis?
- Intense pruritus of palms + soles
- Raised bilirubin + clinically detectable jaundice in some
- Abnormal LFTs + raised bile acids
130
OBSTETRIC CHOLESTASIS
| What is the management of obstetric cholestasis?
- Ursodeoxycolic acid first line to improve LFTs + bile acids
- Induce labour at 37–38w to reduce stillbirth risk
- Vitamin K supplementation
131
INFECTIONS + PREGNANCY
What does parvovirus cause in pregnancy?
What is the management?
- Cross placenta > suppression of foetal erythropoiesis > foetal hydrops
- Intrauterine blood transfusions
132
INFECTIONS + PREGNANCY
What is Group B strep (GBS) infection?
What can it cause?
How is it spread?
- Streptococcus agalactiae
- #1 cause neonatal sepsis
- Commonly found in maternal bowel flora
133
INFECTIONS + PREGNANCY
| What are the risk factors of GBS?
- Prematurity, prolonged ROM, previous GBS sibling, maternal pyrexia
134
INFECTIONS + PREGNANCY
| What is the management options for GBS in pregnancy?
Intrapartum IV benzylpenicillin if:
– Previous GBS pregnancy (or can test in late pregnancy with Abx if positive)
– Previous baby with GBS
– Pyrexia >38º in labour
135
INFECTIONS + PREGNANCY
| What are the maternal and foetal risks of Varicella zoster?
- Maternal risk = 5x greater risk of pneumonitis
| - Foetal varicella syndrome = skin scarring, microphthalmia, limb hypoplasia, microcephaly + learning difficulties
136
INFECTIONS + PREGNANCY
| What is the management of chickenpox exposure in pregnancy?
- Any doubt in immunity, check for varicella zoster IgG
- ≤20w + not immune = VZIG within 10d
- >20w + not immune = VZIG or aciclovir days 7–14 post-exposure
137
INFECTIONS + PREGNANCY
| What is the management of chickenpox infection in pregnancy?
- PO aciclovir if ≥20w + presents within 24h of rash onset
| - <20w then consider
138
INFECTIONS + PREGNANCY
| What is the management of Hep B in pregnancy?
- Babies born to Hep B +ve mothers should be vaccinated within 24h of birth as well as other times recommended on vaccination schedule
139
INFECTIONS + PREGNANCY
What are the risks of rubella in pregnancy?
What is the management?
- Congenital rubella syndrome in first 8–10w (sensorineural deafness, CHD, congenital cataracts, cerebral palsy)
- Discuss with local health protection unit, do not offer live vaccines like MMR in pregnancy (offer postnatally)
140
ANAEMIA + PREGNANCY
Why is anaemia common in pregnancy?
When is it screened for?
- Hb normally falls slightly in pregnancy due to increased plasma volume diluting Hb
- Booking and 28w
141
ANAEMIA + PREGNANCY
| What are the cut-off values for anaemia in pregnancy?
FBC
- 1st trimester <110
- 2nd/3rd trimester <105
- Postpartum = <100
142
ANAEMIA + PREGNANCY
| What is the management of anaemia in pregnancy?
- Ferrous sulfate/fumarate and continue for 3m after deficiency corrected
143
ACUTE FATTY LIVER
What is acute fatty liver of pregnancy?
How does it present?
What is the management?
- Rapid accumulation of fat within the hepatocytes that occurs in the third trimester of pregnancy
- Abdo pain, N+V, jaundice, raised ALT
- Supportive care, delivery definitive
144
THYROID + PREGNANCY
What is the management of hyperthyroidism in pregnancy?
What is the management of hypothyroidism in pregnancy?
- Propylthiouracil choice in 1st trimester as carbimazole causes foetal abnormalities
- Levothyroxine safe but often needs 50% dose increase as early as first 4–6w
145
EPILEPSY + PREGNANCY
| What is the management of epilepsy in pregnancy?
- Preconception = 5mg folic acid, aim for monotherapy = lamotrigine or carbamazepine safest
146
PROM
| What is prelabour rupture of membranes (PROM) and preterm prelabour rupture of membranes (PPROM)?
- Rupture of amniotic sac at least 1h prior to onset of labour at >37w
- Rupture of amniotic sac prior to onset of labour pre-term <37w
147
PROM
| What are some investigations for PROM?
- Sterile speculum 1st for pooling of amniotic fluid
- USS may show oligohydramnios if speculum normal
- Test fluid for insulin-like growth factor-binding protein 1 (IGFBP-1) or placental alpha-microglobin-1 (PAMG-1)
- CTG for foetus (tachycardia is suggestive of infection)
148
PROM
| What are some complications of PPROM?
- Maternal = chorioamnionitis
| - Foetal = prematurity, pulmonary hypoplasia
149
PROM
| What is the management of PPROM?
- Maternal corticosteroids if foetus <34w
- Prophylactic PO erythromycin given to prevent chorioamnionitis for 10d
- Consider induction at 34w (trade off)
150
PREMATURITY
What is the WHO definition of prematurity?
What are the causes?
- Birth before 37w
- Spontaneous = PPROM, cervical weakness, amnionitis
- Iatrogenic = induced labour due to a complication
151
PREMATURITY
What is the clinical presentation of prematurity?
What are some risk factors?
- Persistent uterine activity WITH change in cervical dilatation ± effacement
- Multiple pregnancy, IUGR, APH, polyhydramnios
152
PREMATURITY
| What are the investigations for prematurity?
- <30w = speculum (cervical dilation + look for amniotic fluid)
- >30w = TV USS to measure cervical length (<15mm + contractions diagnostic > offer Mx)
- Foetal fibronectin test = positive in premature labour
153
PREMATURITY
| What are the complications of prematurity?
- Neonatal = NEC, RDS, intraventricular haemorrhage, retinopathy of prematurity
154
PREMATURITY
| What is the prophylaxis for prematurity and how do they work?
- PV progesterone gel if cervical length <25mm at 16–24w
- Cervical cerclage if <25mm at 16–24w with previous premature birth or cervical trauma
- Rescue cerclage at 16–27+6 if cervical dilatation without ROM
155
PREMATURITY
| What is the acute management of premature labour?
- Senior input with foetal CTG monitoring
- Corticosteroids if <34w to aid surfactant production + lung development
- Tocolysis = nifedipine or oxytocin antagonist atosiban
- IV magnesium sulfate = neuroprotection + reduce risk of cerebral palsy
- Delayed cord clamping > increase blood volume + Hb
156
STAGES OF LABOUR
| What are signs of labour?
- Show (shedding of mucus plug)
- Rupture of membranes
- Shortening + dilation of cervix
- Regular painful contractions
157
STAGES OF LABOUR
What is the first stage of labour?
How is it further divided?
- From onset of labour (true contractions) until the cervix is fully dilated (10cm)
- Latent phase = from 0–3cm dilation. About 6h.
- Active phase = from 3–10cm. About 12h.
158
STAGES OF LABOUR
| During the active phase, how quickly do you expect dilation to occur?
- Primis = 0.5cm/h, multiparous = 1cm/h
159
STAGES OF LABOUR
What is the second stage of labour?
How is it further divided?
- From full dilation to delivery of the foetus
- Passive stage: complete dilation but no pushing (often 1 hour)
- Active stage: maternal pushing until delivery
160
STAGES OF LABOUR
What is considered a delay in the active second stage of labour?
What does success depend on?
- >2h in nulliparous, 1h in multiparous
| - 3Ps (power, passenger + passage [?Psyche of mum])
161
STAGES OF LABOUR
Once the foetus has been delivered, what should be assessed and when?
What does it calculate?
- APGAR score at 1, 5 + 10 minutes
- 10–7 = normal
- 6–4 = moderately depressed
- <4 = severely depressed
162
STAGES OF LABOUR
| What are the parts of the APGAR score?
Activity – absent 0, flexed arms + legs 1, active 2
Pulse – absent 0, <100bpm 1, >100bpm 2
Grimace – floppy 0, minimal response to stimulation 1, prompt response to stimulation 2
Appearance – blue 0, blue extremities 1, pink 2
Respiration – absent 0, slow + irregular 1, vigorous cry 2
163
STAGES OF LABOUR
What is the third stage of labour?
What should it involve?
- From birth of the foetus to expulsion of placenta
| - Examine placenta to ensure complete as retained products > PPH or infection
164
STAGES OF LABOUR
What can be used when monitoring labour?
How can they be useful?
Partogram is record of key maternal + foetal data –
- FHR, contractions, maternal pulse, BP, temp
- Drugs, IV fluids + cervical dilation noted
- Have alert + action line > take action
165
STAGES OF LABOUR
What are the 6 cardinal movements of labour?
Note the key foetal head positions too
- Engagement + descent (occiput transverse)
- Flexion
- Internal rotation
- Extension (crowning = occiput anterior)
- Restitution/external rotation
- Expulsion
166
STAGES OF LABOUR
| Why does internal rotation occur?
- Foetus negotiating pelvic inlet which has widest diameter transverse
167
STAGES OF LABOUR
| Why does restitution/external rotation occur?
- Negotiate pelvic outlet as widest diameter anterior/posterior
168
FAILURE TO PROGRESS
| What are the 2 types of abnormal progression in labour?
- Slow from beginning (primary dysfunctional labour) – may be insufficient uterine contractions
- Sudden slowing of labour (secondary arrest) – may be cephalopelvic disproportion
169
FAILURE TO PROGRESS
What may be calculated when considering inducing labour?
What does it calculate?
- Bishop score = used to calculate how likely spontaneous labour is to occur
- Score <5 = unripe cervix (less likely for induction success)
- Score ≥8 = favourable cervix ready for labour or induction
170
FAILURE TO PROGRESS
| What are the components of the Bishop score?
- Cervical dilation – <1cm (0), >5cm (3)
- Cervical consistency – firm (0), intermediate (1), soft (2)
- Cervical effacement – <30% (0), 80% (3)
- Cervical position – posterior (0), intermediate (1), anterior (2)
- Foetal station – –3 (0), ≥1 (3)
171
FAILURE TO PROGRESS
| What are some methods of inducing labour?
- Membrane sweep (often 40/41w antenatal visit)
- Vaginal prostaglandin E2 (PGE2) pessary to ripen cervix
- Maternal oxytocin infusion to stimulate contractions
- Amniotomy
- Cervical ripening balloon
172
FAILURE TO PROGRESS
What is a complication of labour induction?
What is the management?
- Uterine hyperstimulation = frequent uterine contractions
| - Remove vaginal PGE2/stop oxytocin infusion, tocolytic terbutaline
173
FAILURE TO PROGRESS
| What is the aetiology of failure to progress in labour?
- Power (most common)
- Passage
- Passenger
- Psyche (maternal exhaustion in second stage)
174
FAILURE TO PROGRESS
How can 'power' cause failure to progress?
Who is it common in?
- Poor uterine contractions
| - Common in primigravida women
175
FAILURE TO PROGRESS
How can 'passage' cause failure to progress?
What can be a consequence of this?
- Inadequate pelvis, cephalopelvic disproportion
| - Obstructed labour = common in developing countries
176
FAILURE TO PROGRESS
| How can 'passenger' cause failure to progress?
- Size = macrosomia, size of head
- Attitude = posture of foetus
- Lie = longitudinal, transverse, oblique
- Presentation = part closest to cervix
177
FAILURE TO PROGRESS
| How would you manage failure to progress in the second stage of labour?
- Allow to push for 2h if nulliparous or 1h if multiparous
| - May need episiotomy, instrumental delivery or c-section
178
FAILURE TO PROGRESS
How is failure to progress in the third stage of labour defined?
How would you manage this?
What is a potential risk?
- Delay = >30m if active Mx or >60m with physiological
- Oxytocin to cause uterus contraction + expel placenta
- Cord clamp + careful cord traction to guide placenta out (excessive force > snapped cord or uterine inversion)
179
BREECH
| What are the types of breech presentation?
- Extended (Frank) = #1 = hips flexed, knees extended, buttocks presenting
- Flexed (Complete) = hips + knees flexed so buttocks + feet presenting (cannonballing)
- Footling = one/both feet come first with buttocks higher
180
BREECH
What complication is more common in breech presentations?
What are some risk factors of breech?
- Cord prolapse
| - Fibroids, placenta praevia, poly/oligohydramnios, prematurity
181
BREECH
| What are the investigations for breech?
- Abdominal exam = longitudinal lie, head palpated at fundus
| - Dx on antenatal USS, <36w = not important unless woman in labour
182
BREECH
| What is the management of breech?
- External cephalic version (ECV) = 36w nulliparous or 37w multiparous
- C-section if ECV is unsuccessful or contraindicated
183
BREECH
| What are some contraindications for ECV?
- APH within 7d
- Multiple pregnancies
- Abnormal CTG
184
FOETAL LIE
What is foetal lie?
What are the types?
- Long axis of foetus relative to longitudinal axis of uterus
- Longitudinal, transverse, oblique, unstable (actively changing)
185
FOETAL LIE
| What are some risk factors for foetal lie?
- Multiple pregnancy
- Polyhydramnios
- Fibroids
186
FOETAL LIE
| What are some investigations for foetal lie?
- Abdo exam = neither head nor buttocks presenting
| - USS can be used to confirm lie, often antenatally
187
FOETAL LIE
| What are some complications of abnormal lie?
- PROM
| - Cord prolapse (highest risk in transverse lie)
188
FOETAL LIE
| What is the management for foetal lie?
- <36w = none as most will spontnaeously > longitudinal
| - >36w = ECV even in early labour if membranes intact or c-section
189
FOETAL LIE
| What are the contraindications to ECV for transverse lie?
- Maternal rupture in last 7d
- Multiple pregnancy (except for 2nd twin)
- Major uterine abnormality
190
CTG
| How do you interpret a CTG?
Dr C Bravado –
- Dr = define risk (high risk = continuous)
- C = contractions (bottom trace shows frequency)
- Bra = baseline rate
- V = variability
- A = accelerations
- D = decelerations
- O = overall assessment
191
CTG
| What might different foetal baseline rates tell you?
- >160 may be maternal pyrexia, prematurity, chorioamnionitis
- <110 may be maternal beta-blockers, increased foetal vagal tone
192
CTG
| What does variability tell you?
- Reduced variability may be hypoxia, lactic acidosis, prematurity
- 40m reduced variability accepted as baby may be sleeping
193
CTG
What are accelerations?
What do they show you?
- Rise in baseline HR by 15 for ≥15s
| - Reassuring as baby moving
194
CTG
What are decelerations?
What are the 3 types and their causes?
- Fall in baseline HR by 15 for ≥15s
- Early = peak of contraction corresponds with trough of depression (head compression from uterine contraction = normal)
- Late = deceleration after contraction (hypoxia = placental insufficiency, asphyxia)
- Variable = vary in shape + timing (cord compression)
195
CTG
What are the features of a reassuring CTG for...
i) baseline?
ii) variability?
iii) accelerations?
iv) decelerations?
i) 110–160bpm
ii) >5bpm
iii) Present
iv) Early
196
CTG
What are the features of a non-reassuring CTG for...
i) baseline?
ii) variability?
iii) decelerations?
i) 100–109bpm or 161–180bpm
ii) <5bpm for 40–90m
iii) Variable
197
CTG
What are the features of an abnormal CTG for...
i) baseline?
ii) variability?
iii) decelerations?
i) <100bpm or >180bpm
ii) <5bpm for >90m
iii) Late
198
CORD PROLAPSE
What is cord prolapse?
What is the danger?
- Umbilical cord descends ahead of presenting part of foetus which can lead to compression of cord or cord spasm > foetal hypoxia + morbidity or mortality
199
CORD PROLAPSE
| What are some risk factors for cord prolapse?
- Prematurity
- Polyhydramnios
- Multiple pregnancy
200
CORD PROLAPSE
| What are the investigations for cord prolapse?
- Diagnosis on vaginal exam = cord at introitus or palpable vaginally
- Foetal CTG distress (heart decelerations + bradycardia)
201
CORD PROLAPSE
| What is the management of cord prolapse?
- 999/emergency buzzer, senior team
- Delivery = c-section (can trial instrumental if cervix dilated)
- Knees to chest position
- Push presenting part back into uterus to prevent compression
- Fill bladder with 500ml warmed saline
- Avoid exposure + cord handling as can cause spasm
- Tocolytics to abolish contractions
202
SHOULDER DYSTOCIA
What is shoulder dystocia?
What are some risk factors?
- Failure of anterior shoulder to pass under the pubic symphysis after delivery of foetal head
- Foetal macrosomia, DM, high maternal BMI
203
SHOULDER DYSTOCIA
| What are some complications of shoulder dystocia?
- Maternal = PPH, perineal tears
| - Neonatal = hypoxia, brachial plexus injury, cerebral palsy, death
204
SHOULDER DYSTOCIA
| What is the management of shoulder dystocia?
HELPERR –
- Help (emergency buzzer, seniors)
- Evaluate for episiotomy (enlarge opening)
- Legs = McRobert's
- Pressure = suprapubic
- Enter = pelvis for rotation = Rubin II, woods' screw + reverse woods' screw
- Remove = posterior arm
- Replace = head in vagina + deliver by c-section (Zavanelli)
205
SHOULDER DYSTOCIA
What is McRobert's manoeuvre?
Why is it done?
- Hips fully flexed + abducted (knees to abdo)
| - Posterior pelvic tilt lifting symphysis pubis up + out of way
206
INSTRUMENTAL DELIVERY
| What are the types of instrumental delivery?
- Ventouse = suction cup on a cord on baby's head with traction
- Forceps = 2 curved pieces of metal attach either side of baby's head + grip with traction
207
INSTRUMENTAL DELIVERY
| What are the main risks of ventouse delivery?
- Cephalohaematoma = collection of blood between periosteum + skull, does not cross suture lines, presents hours after
- Caput Succedaneum = Crosses Sutures, diffuse oedema outside periosteum, resolve in few days, conehead present at birth
208
PAIN RELIEF
| What are some non-pharmacological pain relief for labour?
- Hypnotherapy
- Water birth
- Controlled breathing
- TENS
209
PAIN RELIEF
| What simple analgesia can be used in labour?
- Paracetamol + codeine useful in early labour
| - Avoid NSAIDs
210
PAIN RELIEF
What is Entonox?
What are the pros?
What are the cons?
- Gas + air (nitrous oxide + O2 50/50 mixed)
- Rapid onset, self-limiting
- N+V, dizziness
211
PAIN RELIEF
| What opioids can be used for pain relief?
- Single shot IM opioids (diamorphine, pethidine > avoid in patients with epilepsy as can cause seizures)
212
PAIN RELIEF
What more invasive management may be offered?
What are some adverse effects?
- Epidural or spinal with bupivacaine
| - Post-dural puncture headache, prolonged 2nd stage, increased probability of instrumental delivery
213
PERINEAL TEARS
| What are some risk factors for perineal tears?
- Macrosomia
- Shoulder dystocia
- Forceps
214
PERINEAL TEARS
What is a first degree perineal tear?
How is it managed?
- Injury to superficial skin, no muscle involvement
| - Do NOT require repair
215
PERINEAL TEARS
What is a second degree perineal tear?
How is it managed?
- Injury to perineal muscle but NOT anal sphincter
| - Suturing on ward by experienced midwife or clinician
216
PERINEAL TEARS
What is a third degree perineal tear?
How is it managed?
- Injury involving anal sphincter complex (3A <50% EAS, 3B >50% EAS, 3C IAS torn)
- Repair in theatre by clinician
217
PERINEAL TEARS
What is a fourth degree perineal tear?
How is it managed?
- Injury to perineum, anal sphincter complex AND rectal mucosa
- Repair in theatre by clinican
218
PROLONGED PREGNANCY
What is a prolonged pregnancy?
What are the complications with this?
- Pregnancy exceeding 42w from LMP
| - Macrosomia, oligohydramnios, reduced placental perfusion, meconium aspiration syndrome > severe pneumonitis
219
UTERINE RUPTURE
What is a uterine rupture?
What are some risk factors?
- Complication of labour where myometrium bursts
| - VBAC, previous uterine surgery, increased BMI, oxytocin
220
UTERINE RUPTURE
| What are the clinical features of uterine rupture?
- Tenderness over previous uterine scars
- PV bleed, maternal shock
- CTG = foetal distress + no or cessation of contractions
221
UTERINE RUPTURE
| What is the management of uterine rupture?
- ABCDE and emergency c-section
222
AMNIOTIC EMBOLISM
What is an amniotic fluid embolism?
What are some risk factors?
- Amniotic fluid/foetal cells enter mother's blood stream causing an immune reaction
- Increasing maternal age + induction of labour
223
AMNIOTIC EMBOLISM
| What is the clinical presentation of amniotic fluid embolism?
- During labour or immediate postpartum
- Symptoms = SOB, sweating, anxiety
- Signs = hypoxia, shock, arrhythmia + MI
224
AMNIOTIC EMBOLISM
| What is the management of amniotic fluid embolism?
- ABCDE approach
| - Critical care management often supportive
225
PPH
What is a postpartum haemorrhage (PPH)?
What are the classifications?
Primary = loss of >500ml blood in the first 24h after delivery
- Minor = 500–1000ml EBL
- Major = >1000ml, clinically in shock
Secondary = excessive blood loss from genital tract between 24h–12w after delivery
226
PPH
| What are the causes of PPH?
Primary (4Ts) –
- Tone (uterine atony = most common)
- Trauma (perineal tear)
- Tissue (retained products)
- Thrombin (clotting issue e.g. DIC in pre-eclampsia)
Secondary most common cause is retained placental tissue > endometritis
227
PPH
| What are the before birth and during labour risk factors for PPH?
- Before birth = APH, previous PPH, multiple pregnancy
| - Labour = c-section, perineal tear, macrosomia
228
PPH
| How might uterine atony present in PPH?
- Unpalpable uterus on abdo exam (should normally be palpable in period following birth)
229
PPH
| What are some preventative measures to reduce risk and consequences of PPH?
- Empty bladder as full bladder reduces uterine contractions
- Active Mx of third stage (oxytocin)
- IV TXA during c-section in third stage of labour if high risk
230
PPH
| What is the initial acute management of PPH?
- ABCDE resus = 2x large bore cannulas, X match, major haemorrhage protocol, IV fluids
- Mechanically massage uterus through abdomen
231
PPH
| What is the medical management of PPH?
- IV syntocinon or IV ergometrine (can combine as syntometrine) but ergometrine C/I in HTN as vasoconstrictor
- IM carboprost (prostaglandin analogue = caution in asthma)
- Sublingual misoprostol (prostaglandin analogue)
232
PPH
| After failed medical management, what is the the recommended management of PPH?
- Intrauterine balloon tamponade (1st line in uterine atony)
- Other surgical = B-lynch sutures, ligation of uterine or internal iliac arteries
- Hysterectomy as last resort (may save life)
233
```
PUERPERAL PYREXIA
What is puerperal pyrexia?
What are the causes?
What is the presentation of the most common cause?
What is the management
```
- Temp >38 in first 14d postpartum
- Endometritis #1, UTI, mastitis, VTE
- Foul smelling discharge, heavy bleeding, abdo pain
- Endometritis = hospital for IV Abx (clindamycin/gent)
234
NEWBORN SCREENING
| What is the process of the newborn blood spot conditions screen (Guthrie/heel-prick)?
- Screening on day 5–9
| - Residual blood spots stored for 5 years (part of consent process) for research
235
NEWBORN SCREENING
| What conditions does the newborn blood spot screen for?
```
3 genetic –
- Sickle cell disease
- Cystic fibrosis
- Congenital hypothyroidism
6 inherited metabolic –
- Phenylketonuria
- Medium-chain acyl-CoA dehydrogenase deficiency
- Maple syrup urine disease
- Isovaleric acidaemia
- Glutaric aciduria type 1
- Homocystinuria
```
236
NEWBORN SCREENING
What is the rough incidence of...
i) sickle cell disease?
ii) cystic fibrosis?
iii) congenital hypothyroidism?
iv) phenylketonuria?
v) MCADD?
vi) MSUD?
vii) IVA?
viii) GA1?
ix) homocystinuria?
i) 1 in 2000
ii) 1 in 2500
iii) 1 in 3000
iv) 1 in 10,000
v) 1 in 10,000
vi) 1 in 150,000
vii) 1 in 150,000
viii) 1 in 300,000
ix) 1 in 300,000
237
NEWBORN SCREENING
What specifically is tested for in...
i) cystic fibrosis?
ii) congenital hypothyroidism?
iii) phenylketonuria?
i) Immunoreactive trypsinogen
ii) TSH
iii) Phenylalanine
238
NEWBORN SCREENING
What does the newborn hearing screen involve?
What is the outcome?
- All babies screened within 4w of birth ideally (up to 3m)
- Otoacoustic emission test
- If above abnormal = auditory brainstem response test
239
MENTAL HEALTH
What are baby blues?
What is the management?
- Brief period of tearfulness, anxiety + emotional lability, 3–7d after birth
- Reassurance + health visitor surveillance
240
MENTAL HEALTH
What is postnatal depression?
How can it be screened for?
- Depressive episode, temporally related to childbirth, often within 1m
- Edinburgh postnatal depression scale
241
MENTAL HEALTH
| What is the management of postnatal depression?
- CBT
| - SSRIs sertraline or paroxetine ok in breastfeeding
242
MENTAL HEALTH
What is postpartum/puerperal psychosis?
What is the management?
- Acute psychotic episode often 2–3w postpartum
| - Manage with admission to hospital, ideally Mother and Baby unit
243
SHEEHAN'S SYNDROME
What is Sheehan's syndrome?
What is the management?
- Pituitary necrosis secondary to a PPH
| - Replacement of deficient hormones
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SHEEHAN'S SYNDROME
| How does Sheehan's syndrome present?
- Low ACTH = adrenal insufficiency
- Low LH + FSH = amenorrhoea, infertility, loss of libido
- Low TSH = hypothyroidism
- Low prolactin = reduced lactation
